Original Article

Role of Cyclosporine Eye Drops In Allergic Conjunctivitis Ather Jameel, Muhammad Moin, Mumtaz Hussain.

Pak J Ophthalmol 2009, Vol. 25 No. 2 . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . See end of article for

Purpose: To evaluate the effects of topical 2% cyclosporin eye drops in patients

authors affiliations

with active vernal keratoconjunctivitis.

… ………………………

Material

and

Methods:

Thirty

seven

patients

with

active

vernal

keratoconjunctivitis diagnosed at least one year before and treated with a variety

Correspondence to:

of topical medications except cyclosporin were included in the study. All patients

Ather Jameel

were treated with 2% cyclosporin eye drops four times daily in both eyes for 6

Department of Ophthalmology

weeks. Symptoms (itching, watering, photophobia, mucous discharge and

Mayo Hospital

foreign body sensation) and signs (conjunctival hyperemia, trantas’ dots, limbal

Lahore

oedema, epithelial punctate keratitis and palpebral conjunctival papillae) of vernal keratoconjunctivitis were recorded before treatment and at the end of treatment period. Results:

There

was

a

statistically

significant

improvement

in

itching,

photophobia, mucous discharge, conjunctival hyperemia, punctate keratitis and trantas’ dots after 6 weeks treatment period. No significant adverse effect of treatment with topical cyclosporin was observed except for mild to moderate Received for publication

stinging and burning upon administration.

September’ 2008

Conclusion: Topical cyclosporin is an effective and safe agent in the treatment of

… ………………………

vernal keratoconjunctivitis.

V

ernal keratoconjunctivitis (VKC) is an ocular allergic disease predominantly observed in children and young adults1. The disease is usually bilateral and is seen more commonly among

males2. Patients with vernal keratoconjunctivitis may suffer from symptoms throughout the year, but the intensity of the disease may increase in spring and summer. The precise immunopathogenic mechanism

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is unknown but it is thought to be more complex than a simple type I hypersensitivity reaction3. Therapy of vernal keratoconjunctivitis includes the use of topical vasoconstrictors, antihistamines, mast cell stabilizers and corticosteroids4. The most effective treatment for vernal keratoconjunctivitis is stopical and supratarsal injection of corticosteroids, but this treatment carries considerable risk of complications5. Although the disease is self limiting, signs and symptoms are often severe and difficult to control. Corneal complications in untreated cases and prolonged steroid treatment in treated cases may lead to permanent impairment of vision. Therefore the search for new, effective and safe treatments of this potentially blinding disease continues. Cyclosporin is an immunosuppressive agent that specifically inhibits helper T-lymphocyte proliferation and production of interleukin-26. It is therefore inhibitory to many T-cell-dependent inflammatory mechanisms. It has direct inhibitory effects on eosinophil activation, release of granule proteins and cytokines. It also has direct and indirect inhibitory effects on mast cell activation, cytokine and mediator release, which are likely to be important in its role in the treatment of allergic inflammation7.

the upper palpebral conjunctiva or by gelatinous hypertrophy of the limbus, associated with typical vernal epithelial keratitis. After taking informed consent patients were enrolled in the study. All patients were placed on a one week washout period. During that period patients were requested not to instill any eye drops in their eyes and parents were instructed to apply cold compresses whenever their children complained of symptoms related to the disease. After this washout period detailed ophthalmic and systemic history for associated disorders was recorded and a complete ophthalmological examination was performed. Specific evaluation of the following symptoms and signs was carried out. Symptoms include itching, watering, photophobia, mucous discharge and foreign body sensation. Signs include conjunctival hyperemia, punctate keratitis, trantas’ dots, limbal oedema and palpebral conjunctival papillae. All patients were given 2% cyclosporin eye drops four times daily in both eyes. Symptoms and signs were recorded before treatment and after 1st, 3rd and 6th week of treatment. Grading of Symptoms

To avoid the complications of current treatment of severe VKC (especially steroid), the efficacy of cyclosporin regarding the control of symptomatology of VKC was studied. MATERIALS AND METHODS

Symptoms were graded as follows: 0= indicating no symptoms 1+= mild symptoms of discomfort which were just noticeable. 2 + = moderate discomfort noticed most of the day but did not interfere with daily routine activities. 3+ = severe symptoms interfering with daily routine activities.

The study was conducted at the Institute of Ophthalmology, Mayo Hospital Lahore from March to May 2002. A total of 37 patients were included in this Quasi experimental study.

Grading of Signs Conjunctival hyperemia was graded as follows: 0= no evidence of bulbar hyperemia. 1+ = mild bulbar hyperemia. 2+ = moderate bulbar hyperemia. 3+ = severe bulbar hyperemia.

Patients included in the study were known cases of active palpebral or limbal vernal keratoconjunctivitis diagnosed at least one year before and treated with a variety of topical medications, except cyclosporin with poor response.

Palpebral conjunctival papillae were graded as follows: 0= no papillary hypertrophy of the palpebral conjunctiva. 1+ = mild papillary hypertrophy. 2+ = moderate papillary hypertrophy (hazy view of the deep tarsal vessels). 3+ = severe papillary hypertrophy (deep tarsal vessels not visible in more than 50% of the surface).

Patients excluded from the study were patients with associated ocular or systemic disease, patients who had history of periocular injections of steroids within a period of six months, patients taking systemic corticosteroids, anti-inflammatory agents or antihistamines and patients with shield ulcer. Patients with VKC were selected according to inclusion and exclusion criteria. VKC was defined as recurrent bilateral conjunctivitis with giant papillae in

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Punctate keratitis was graded as follows: 0= no evidence of punctate keratitis. 1+ = one quadrant of punctate keratitis. 2+ = two quadrants of punctate keratitis. 3+ = three or more quadrants of punctate keratitis.

16-18 Years Sex

Limbal oedema was graded as follows: 0= no evidence of limbal oedema. 1 + = less than 90o of limbal oedema. 2 + = less than 180o of limbal oedema but more than 90o. 3 + = more than 180o of limbal oedema. Blood was collected by antecubital venipuncture before and 6 weeks after the initiation of treatment. Complete blood count, blood urea nitrogen, creatinine, serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT) levels were determined to monitor the systemic side effects of cyclosporin.

Complete blood count showed normal white blood cells counts with differential count showing slight increase in the number of eosinophils. The number of eosinophils in patients of VKC entered in this study ranged between 3% and 13%. No significant difference was found after treatment with topical cyclosporin (Table 4).

There were 32 males and 5 females enrolled in the study. Patients had mean age of 9.8 years (ranged 5 to 18 years). Twenty four (64.9%) of 37 patients were 10 years of age or younger (Table 1) Table 1: Distribution Age and Sex (n =37)

10 (27.0)

5 (13.5)

The intraocular pressure was measured in patients who were co-operative, before, during and six weeks after treatment with topical cyclosporin. There was no significant change in the intraocular pressure after treatment.

RESULTS

11-15 Years

Female

There was a statistically significant improvement in the conjunctival and corneal signs after using topical cyclosporin. Bulbar conjunctival hyperemia improved in 36(97.3%) patients (p